Preoperative Progressive Pneumoperitoneum and Botulinum Toxin A in a High-Risk Patient With Loss of Domain Inguinoscrotal Hernia.

We present a challenging case of a loss of domain (LOD) inguinoscrotal hernia in a 77-year-old high-risk patient, successfully managed with the complementary preoperative use of progressive pneumoperitoneum (PPP) and botulinum toxin A (BTA) without complications. Giant inguinoscrotal and LOD hernias, particularly in multimorbid patients, are highly complex and require meticulous preoperative preparation. In this case, PPP was performed with ambient air and a gradual increase in insufflation volume, while BTA was injected at three points on each side, with a total dose of 300 IU. This approach facilitated a complication-free increase in abdominal cavity volume and the repositioning of chronically eventrated abdominal contents. The technique proved safe, feasible, and effective, contributing to atraumatic adhesiolysis, reduced operative time, and avoidance of more invasive surgical methods. A Shouldice pure tissue repair was performed, successfully avoiding the need for prosthetic materials.